COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE

Blood tests

An elevated ESR or CRP may point to inflammatory conditions such as vas-culitis. Comatose patients may be hypoglycaemic or hyponatraemic, and hypocalcaemia may lead to spasms and tetany.

Imaging

Skull and spinal X-rays are used to identify fractures, metastases, enlarge-ment of the pituitary fossa or intracranial calcification.

Computed tomography (CT) (p. 822) is of value in identifying cerebral tumours, intracerebral haemorrhage and infarction, subdural and extradural haematoma, midline shift of intracranial structures and cerebral atrophy. However, small lesions (<1 cm) or lesions with the same attenuation as bone or brain (e.g. plaques of multiple sclerosis, isodense subdural haematoma) are poorly seen. In addition lesions in the posterior fossa are sometimes missed.

Magnetic resonance imaging (MRI) (p. 826) is of particular value in imaging tumours, infarction, haemorrhage, clot, multiple sclerosis plaques, the posterior fossa, the foramen magnum and the spinal cord. Patients with pacemakers or metallic fragments in the brain cannot be imaged and claus-trophobia is an issue for some patients.

Positron emission tomography (PET) (p. 828) is principally used in the detection of occult neoplasms.

Doppler studies B-mode and colour ultrasound are valuable in the detec-tion of stenosis of the carotid arteries.

Electroencephalography (EEG) The EEG measures brain electrical activ-ity and is recorded from scalp electrodes on 16 channels simultaneously. Its main value is in diagnosing epilepsy and it is a sensitive test for encepha-lopathies; different patterns are seen with different encephalopathies. Patients with epilepsy often have a normal EEG between seizures. Evoked potentials record brain responses to sound (auditory evoked potentials), touch (somatosensory) and visual stimuli (visual evoked potentials).

Lumbar puncture and cerebrospinal fluid (CSF) examination Lumbar puncture (LP) is central to the diagnosis of meningitis and encephalitis, but is also helpful in the diagnosis of other conditions, such as multiple sclerosis, neurosyphilis, sarcoidosis and Behget's disease. It is used therapeutically for intrathecal injection of drugs or for removal of CSF in idiopathic intracranial hypertension. Brain imaging (CT or MRI) should be performed before LP in patients who have clinical features that increase the likelihood of having intracranial mass lesions or increase in CSF pressure which would preclude LP: immunosuppression, bleeding tendency, focal neuro-logical signs, papilloedema, loss of consciousness or seizure. CSF pressure (normally 80-180 mmH2O with small visible excursions related to pulse and respiration) is measured with a manometer and CSF fluid is collected into at least three separate numbered bottles. It should normally be clear and colour-less. A decreasing concentration of red blood cells from bottles 1 to 3 indi-cates a traumatic tap, rather than blood in the CSF (indicating subarachnoid haemorrhage). Fluid should be sent for microscopy and culture, protein, and glucose concentration with a simultaneous plasma glucose sample. Addi-tional investigations depend on the suspected diagnosis. Complications of LP are post-procedure headache, infection, and herniation of the brainstem through the foramen magnum (‘coning').

Electromyography (EMG) records the electrical activity of muscles at rest and during voluntary contraction. Recordings are made by placing a small electrode needle into the muscle. EMG is usually performed in conjunction with nerve conduction studies, which measure the speed of conduction of impulses through a nerve. They will differentiate between axonal and demyelination neuropathy and determine whether pathology is focal or diffuse. These tests are used to investigate disease of the muscles, nerves or neuro-muscular junction.

Investigation of suspected muscle disease

Measurement of serum creatine phosphokinase (CK) and aldose, EMG, and muscle biopsy for histology and immunohistochemical staining are the three main investigations used in the diagnosis of muscle disease. Muscle biopsy is performed under local anaesthetic with a small skin incision and muscle biopsy needle. MR imaging demonstrates areas of muscle inflammation, oedema and fibrosis. It can image a large bulk of muscle and avoids the sampling error associated with muscle biopsy. Serial images can be used to assess the response to treatment. Currently it is used as well as and not in place of biopsy.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology



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